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Shanbhag NM, Tom MC, Duncan A, Bin Sumaida A. Impact of Clinical Examination and Gamma Knife Surgery in Stage IV Breast Cancer With Brain Metastasis. Cureus 2024; 16:e51831. [PMID: 38196988 PMCID: PMC10776030 DOI: 10.7759/cureus.51831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/11/2024] Open
Abstract
Metastatic breast cancer often presents with significant diagnostic and treatment challenges. This case report highlights the crucial role of thorough clinical examination and history-taking in diagnosing and managing a patient with metastatic breast cancer, mainly focusing on the successful integration of Gamma Knife radiosurgery (GKRS). We present a case of a 68-year-old postmenopausal woman with metastatic breast cancer, initially presenting with a primary tumour in the left breast and later developing a solitary brain metastasis (BM) in the left temporal lobe. Following neoadjuvant chemotherapy and left mastectomy, the patient experienced involuntary movements in the right arm, leading to the discovery of the brain lesion. Critical to this diagnosis was a detailed clinical examination emphasising the importance of vigilant monitoring in cancer management. The patient underwent GKRS, offering a focused and less invasive treatment approach with favourable outcomes. This case underscores the value of clinical vigilance in managing complex breast cancer cases. The integration of GKRS as a targeted treatment modality for BM represents a pivotal aspect of modern oncological care, especially for patients with multiple treatment modalities. This report emphasizes the importance of clinical examination in the early detection of complications such as BM in breast cancer patients. Furthermore, it demonstrates the effectiveness of GKRS in managing such metastases, reinforcing its role as a valuable tool in the multidisciplinary treatment approach for advanced breast cancer.
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Affiliation(s)
- Nandan M Shanbhag
- Oncology, Tawam Hospital, Al Ain, ARE
- Internal Medicine, United Arab Emirates University, Al Ain, ARE
| | - Martin C Tom
- Radiation Oncology, MD Anderson Cancer Center, Houston, USA
| | - Albert Duncan
- Surgery, Mount St. John's Medical Center, St. John's, ATG
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Pusztai L, Rozenblit M, Dubsky P, Bachelot T, Kirby AM, Linderholm BK, White JR, Chmura SJ, Carey LA, Chua BH, Miller KD. De Novo Oligometastatic Breast Cancer. J Clin Oncol 2023; 41:5237-5241. [PMID: 37607325 PMCID: PMC10691789 DOI: 10.1200/jco.23.00911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/26/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023] Open
Abstract
De novo oligometastatic breast cancer, a unique disease needing new treatment paradigms.
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Affiliation(s)
- Lajos Pusztai
- Yale Cancer Center, Yale School of Medicine, New Haven, CT
| | | | - Peter Dubsky
- Breast Center Hirslanden Klinik St Anna & Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Thomas Bachelot
- Département de Cancérologie Médicale, Centre Léon Bérard, Lyon, France
| | - Anna M. Kirby
- Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, United Kingdom
| | - Barbro K. Linderholm
- Department of Oncology, Sahlgrenska Academy and University Hospital, Gothenburg, Sweden
| | - Julia R. White
- Department of Radiology, University of Kansas, Kansas City, KA
| | - Steven J. Chmura
- Department of Radiation Oncology, University of Chicago, Chicago, IL
| | - Lisa A. Carey
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Boon H. Chua
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Kathy D. Miller
- Department of Medicine Hematology/Oncology Division, University of Indiana, School of Medicine, Indianapolis, IN
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Feng K, Xing Z, Dai Q, Cheng H, Wang X. Role of aggressive locoregional surgery in treatment strategies for ipsilateral supraclavicular lymph node metastasis of breast cancer: a real-world cohort study. Front Mol Biosci 2023; 10:1248410. [PMID: 37916188 PMCID: PMC10616842 DOI: 10.3389/fmolb.2023.1248410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Background: Breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastases (ISLNM) have unfavorable prognoses. The role of supraclavicular lymph node dissection (SLND) as a surgical intervention in the treatment of this condition remains controversial. In this study, we aimed to evaluate the prognostic factors associated with breast cancer with ISLNM and to assess the potential impact of aggressive locoregional surgical management on patient outcomes. Methods: We conducted a retrospective analysis of 250 breast cancer patients with ISLNM who were treated with curative intent at our institution between 2000 and 2020. The cohort was stratified into groups based on the extent of axillary surgery. The first group, comprising 185 patients, underwent level I/II axillary dissection. The second group, consisting of 65 patients, underwent aggressive locoregional surgery, including levels I/II/III (infraclavicular) dissection in 37 patients and levels I/II/III + SLND in 28 patients. Our study evaluated overall survival (OS) and disease-free survival (DFS) as primary endpoints, and locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) as secondary endpoints. Results: The median follow-up time among all patients was 5.92 years (1.05-15.36 years). The 5-year OS rate was 71.89%, while the DFS rate, LRRFS rate, and DMFS rates were 59.25%, 66.38%, and 64.98%, respectively. A significant difference in OS, DFS, LRRFS, and DMFS was observed between the second group and the first group (p < 0.01). No beneficial impact on recurrence, metastasis, or survival outcomes was observed in the levels I/II/III + SLND group compared to the levels I/II/III dissection group. Multivariate logistic regression analysis revealed that levels I/II/III ± SLND surgery and T stage were associated with OS (p = 0.006 and p = 0.026), while levels I/II/III ± SLND surgery, ER+/HER2-, and histologic grade were associated with DFS (p = 0.032, p = 0.001, p = 0.032). Conclusion: Breast cancer with ISLNM may be considered a locoregional disease, requiring a combination of systemic and local therapies. Aggressive locoregional surgery has been shown to positively impact recurrence, metastasis, and survival outcomes. This approach may provide improved management of the ISLNM for breast cancer patients.
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Affiliation(s)
| | | | | | | | - Xiang Wang
- Department of Breast Surgical Oncology, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Li S, Qi W, Cao L, Xu C, Cai R, Chen J, Cai G. Nodal response to primary systemic therapy predicts prognosis of cN3c breast cancer patients receiving multimodality therapy. Breast 2023; 70:92-99. [PMID: 37423063 DOI: 10.1016/j.breast.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023] Open
Abstract
AIM To investigate the survival outcomes, patterns and risks of recurrence in cN3c breast cancer patients after multimodality therapy, as well as the predictors of candidates for ipsilateral supraclavicular (SCV) area boosting. METHOD Consecutive cN3c breast cancer patients from January 2009 to December 2020 were retrospectively reviewed. Based on nodal response to primary systemic therapy (PST), patients were categorized into three groups: clinical complete response (cCR) not achieved in SCV lymph nodal (SCLN, Group A), SCLN cCR but axillary node (ALN) did not achieve pathological complete response (pCR, Group B), cCR in SCLN and pCR in ALN (Group C). RESULTS The median follow-up time was 32.7 months. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64.6% and 43.7% respectively. Multivariate analysis showed cumulative SCV dose and ypT stage, ALN response and SCV response to PST were significantly associated with OS and RFS respectively. Compared with Group A or B, Group C showed significantly improved 3 y-RFS (53.8% vs 73.6% vs 100%, p = 0.003), and the lowest rate of DM as first failure (37.9% vs 23.5% vs 0%, p = 0.010). In Group A, the 3 y-OS for patients receiving the cumulative SCV dose of ≥60 Gy versus <60 Gy was 78.0% versus 57.3% (p = 0.029). CONCLUSION Nodal response to PST is an independent prognostic factor for survival and pattern of failure. A cumulative SCV dose of ≥60 Gy is positively associated with improved OS, especially in Group A. Our data supports the perspective of optimizing radiotherapeutic strategy based on nodal response.
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Affiliation(s)
- Shuyan Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weixiang Qi
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Xu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rong Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Gang Cai
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Jing H, Tang Y, Wang ZZ, Wei R, Jin JY, Li J, Zhao LY, Jin J, Liu YP, Song YW, Fang H, Chen B, Qi SN, Lu NN, Tang Y, Li N, Zhai YR, Zhang WW, Wang SL, Li YX. Individualized Clinical Target Volume for Irradiation of the Supraclavicular Region in Breast Cancer Based on Mapping of the Involved Ipsilateral Supraclavicular Lymph Nodes. Int J Radiat Oncol Biol Phys 2023; 115:922-932. [PMID: 36368434 DOI: 10.1016/j.ijrobp.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/12/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE To map supraclavicular fossa-involved lymph nodes (SCF-LNs) in patients with nonmetastatic breast cancer, evaluate the coverage of widely adopted atlases, and propose modified borders for individualized regional irradiation. METHODS AND MATERIALS M0 patients with biopsy-proven SCF-LNs who were SCF treatment-naïve were included. The SCF was spatially divided into subregions, with each node mapped on the original images. The geographic misses after the borders of multiple atlases were evaluated and factors affecting SCF-LNs' spread pattern were analyzed. RESULTS From 1998 to 2022, 209 patients with 1242 SCF-LNs were eligible. Patients had a median of 4 nodes. At least 537 nodes (43.2%) in 147 patients (70.3%) were lateral to the sternocleidomastoid muscle (SCM), and 403 nodes (32.4%) in 127 patients (60.8%) were dorsal to the anterior scalene muscle (ASM). In the 88 patients with ≤3 SCF-LNs, at least 66 nodes (39.1%) in 40 patients (45.5%) were lateral to the SCM, and 34 nodes (20.1%) in 29 patients (33.0%) were dorsal to the ASM. These nodes were not covered by the Radiation Therapy Oncology Group (RTOG) atlas and partly within the Radiotherapy Comparative Effectiveness atlas. One hundred four patients (49.8%) had 432 SCF-LNs (34.8%) beyond the upper border of the European Society for Radiotherapy and Oncology (ESTRO) atlas. In multivariate regression, nodal sizes were associated with wider spread in the primary group. Being triple-negative (TN) subtype was associated with less spread in the recurrent group. Situation-based clinical target volumes (CTVs) were theorized, in which for a sequential spread, the posterior border could be the posterior scalene muscle or even be more constringent; otherwise, it should touch the anterior trapezius surface. CONCLUSIONS SCF-LNs tend to spread laterally and dorsally beyond the RTOG borders, even in M0 stages with ≤3 SCF-LNs. The ESTRO upper border does not guarantee coverage with multiple SCF-LNs. Nodal burden and non-TN types are predictive of wider dissemination. A situation-based CTV is possibly feasible. Deciphering the SCF-LN spread route is needed.
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Affiliation(s)
- Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zong-Zhan Wang
- Department of Radiation Oncology, Qingdao Central Hospital, Qing Dao, Shan Dong, China
| | - Ran Wei
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Yi Jin
- Department of Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- Department of Radiation Oncology, Beijng Hospital, Beijing, China
| | - Li-Yun Zhao
- Department of Radiation Oncology, Beijng Hospital, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Rui Zhai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Song YC, Kong J, Li N, Liu XL, Li XH, Zhu LY, Wang YW, Fang H, Jing H, Tang Y, Li YX, Wang XH, Zhang J, Wang SL. Comparison of supraclavicular surgery plus radiotherapy versus radiotherapy alone in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis: a multicenter retrospective study. Radiother Oncol 2023; 183:109639. [PMID: 36990395 DOI: 10.1016/j.radonc.2023.109639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/27/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE To evaluate and compare the outcomes of supraclavicular lymph node dissection plus radiotherapy (RT) and RT alone for patients with synchronous ipsilateral supraclavicular lymph node metastasis. METHODS In all, 293 patients with synchronous ipsilateral supraclavicular lymph node metastasis across three centers were included. Of these, 85 (29.0%) received supraclavicular lymph node dissection plus RT (Surgery + RT) and 208 (71.0%) received RT alone. All patients received preoperative systemic therapy followed by mastectomy or lumpectomy and axillary dissection. Supraclavicular recurrence-free survival (SCRFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated by using the Kaplan-Meier method and multivariate Cox models. Multiple imputation was used for missing data. RESULTS The median follow-up duration of the RT and Surgery + RT groups were 53.7 and 63.5 months, respectively. For the RT and Surgery + RT groups, the 5-year SCRFS rates were 91.7% vs. 85.5% (P=0.522), LRRFS rates were 79.1% vs. 73.1% (P=0.412), DMFS rates were 60.4 vs. 58.8% (P=0.708), DFS rates were 57.6% vs. 49.7% (P=0.291), and OS rates were 71.9% vs. 62.2% (P=0.272), respectively. There was no significant effect on any outcome when comparing Surgery +RT versus RT alone in the multivariate analysis. Based on four risk factors of DFS, patients were classified into three risk groups: the intermediate- and high-risk groups had significantly lower survival outcomes than the low-risk group. Surgery +RT did not improve outcomes of any risk group compared with RT alone. CONCLUSIONS Patients with synchronous ipsilateral supraclavicular lymph node metastasis may not benefit from supraclavicular lymph node dissection. Distant metastasis remained the major failure pattern, especially for intermediate- and high-risk groups.
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A multi-center cross-sectional investigation of the diagnosis and treatment of breast cancer with synchronous ipsilateral supraclavicular lymph node metastases based on the CSBrs-009. CLINICAL & TRANSLATIONAL ONCOLOGY : OFFICIAL PUBLICATION OF THE FEDERATION OF SPANISH ONCOLOGY SOCIETIES AND OF THE NATIONAL CANCER INSTITUTE OF MEXICO 2023; 25:1482-1487. [PMID: 36611099 DOI: 10.1007/s12094-022-03053-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/17/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The diagnosis and management of breast cancer with ipsilateral supraclavicular lymph node metastases currently lack any applicable criteria or guidelines (ISLM), and diagnostic and treatment strategies are varied by medical centers. This study aimed to determine the current status of the diagnosis and treatment of breast cancer with ISLM among Chinese patients. METHODS Data from 30 hospitals on ISLM breast cancer patients between January 1, 2018, and December 31, 2018, were systematically analyzed for the detection rate, clinicopathological characteristics, diagnosis and treatment strategies of breast cancer with ISLM among Chinese patients. RESULTS A total of 26,723 women presented with breast cancer in 30 hospitals over the study period. A total of 127 ISLM breast cancer patients were finally enrolled. Synchronous ISLM without distant metastases was present in 0.48% of cases. The diagnosis of patients with 86.6% of ISLM was based on ultrasound examinations. The proportion of ISLM diagnosed by fine-needle aspiration biopsy (FNA) or core-needle biopsy (CNB) before surgery was 16.5% and 37.0%, respectively. Moreover, 45.7% of the ISLM patients had no pathological evidence. Regarding treatment strategies, 69.3% of ISLM patients received neoadjuvant chemotherapy (NAC) for more than 4 cycles, while 15.7% of patients did not receive NAC. 86.6% of ISLM patients underwent a mastectomy, and breast-conserving surgery was performed in 3.9% of ISLM patients. Moreover, 41.7% of ISLM patients received supraclavicular lymph node dissection (SCLD), while 47.2% were not treated with SCLD. CONCLUSIONS The overall detection rate of breast cancer in patients with ISLM is low in China and varies widely between hospitals. There is no consensus on the optimal diagnosis and treatment of patients with ISLM breast cancer.
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Cobb AN, Sun SX. ASO Author Reflections: Inflammatory Breast Cancer with Supraclavicular Nodal Involvement-Favorable Long-Term Outcomes can be Achieved. Ann Surg Oncol 2022; 29:6393-6394. [PMID: 35842535 DOI: 10.1245/s10434-022-12235-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 11/18/2022]
Affiliation(s)
- A N Cobb
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - S X Sun
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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Cobb AN, Diao K, Teshome M, Lucci A, Ueno NT, Stauder M, Layman RM, Kuerer HM, Woodward WA, Sun SX. Long-term Oncologic Outcomes in Patients with Inflammatory Breast Cancer with Supraclavicular Nodal Involvement. Ann Surg Oncol 2022; 29:6381-6392. [PMID: 35834145 DOI: 10.1245/s10434-022-12144-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inflammatory breast cancer (IBC) is a rare and aggressive subtype of breast cancer characterized by rapid progression and early metastasis, often with advanced nodal locations, including the supraclavicular (SCV) nodal basin. Previously considered M1 disease, ipsilateral clinical supraclavicular node involvement (N3c) disease is now considered locally advanced disease and warrants treatment with intent to cure. The objective of this study was to evaluate the long-term outcomes of patients with IBC and N3c disease. PATIENTS AND METHODS This study was conducted using a prospectively collected database of all patients with IBC treated at a dedicated cancer center from 2007 to 2019. Surgical patients with SCV nodal involvement and complete follow-up were identified. Our primary outcome was 5-year overall survival (OS). Multivariate Cox proportional hazards models were used to determine predictors for survival. Event-free survival (EFS) and OS were calculated using the Kaplan-Meier method. RESULTS There were 70 patients who met inclusion criteria. All patients underwent comprehensive trimodality therapy. The majority of patients had complete (66.2%) radiologic response in the SCV nodal basins following neoadjuvant therapy. Six patients (8.6%) had a locoregional recurrence, with two (2.9%) occurring in the supraclavicular fossa. The 5-year OS was 60.2% [95% confidence interval (CI) 47.7-72.7%]. Increasing age (hazard ratio 2.7; p = 0.03) and triple-negative subtype (hazard ratio 4.9; p = 0.03) were associated with poor OS. The 5-year EFS was 56.1% (95% CI 40.9-68.8%). The presence of more than ten positive axillary nodes on final surgical pathology (hazard ratio 5.5; p = 0.01) predicted poor EFS. CONCLUSIONS With comprehensive trimodality therapy and multidisciplinary team approach, patients with IBC with supraclavicular nodal involvement experience excellent locoregional control and favorable survival.
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Affiliation(s)
- Adrienne N Cobb
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin Diao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mediget Teshome
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naoto T Ueno
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Stauder
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rachel M Layman
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susie X Sun
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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10
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Coopey SB. Supraclavicular and Contralateral Axillary Lymph Node Involvement in Breast Cancer Patients. Ann Surg Oncol 2022; 29:6100-6105. [PMID: 35794365 DOI: 10.1245/s10434-022-12134-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/02/2022] [Indexed: 11/18/2022]
Abstract
Ipsilateral supraclavicular disease was reclassified from Stage IV, distant metastatic disease, to Stage IIIC, locally advanced breast cancer 20 years ago. Treatment with curative intent with multimodality therapy has led to improved outcomes over time. In contrast, metastatic disease to contralateral axillary lymph nodes remains as Stage IV distant disease. Despite this, in the absence of other distant metastases, many patients with contralateral axillary disease are treated more aggressively than other Stage IV patients. Outcomes of patients with contralateral axillary disease treated with curative intent are more like patients with ipsilateral supraclavicular disease and other locally advanced breast cancers than patients with de novo distant metastases elsewhere. Therefore, some favor reclassification of contralateral axillary metastases without distant metastasis from Stage IV to Stage III breast cancer similar to ipsilateral supraclavicular metastases.
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Polgár C, Kahán Z, Ivanov O, Chorváth M, Ligačová A, Csejtei A, Gábor G, Landherr L, Mangel L, Mayer Á, Fodor J. Radiotherapy of Breast Cancer—Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer. Pathol Oncol Res 2022; 28:1610378. [PMID: 35832115 PMCID: PMC9272418 DOI: 10.3389/pore.2022.1610378] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022]
Abstract
The international radiotherapy (RT) expert panel has revised and updated the RT guidelines that were accepted in 2020 at the 4th Hungarian Breast Cancer Consensus Conference, based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (stage 0), as RT decreases the risk of local recurrence (LR) by 50–60%. In early stage (stage I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor-positive tumour, hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives to conventional WBI administered for 5 weeks. Following mastectomy, RT significantly decreases the risk of LR and improves overall survival of patients who have 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant systemic treatment (NST) followed by BCS, WBI is mandatory, while after NST followed by mastectomy, locoregional RT should be given in cases of initial stage III–IV and ypN1 axillary status.
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Affiliation(s)
- Csaba Polgár
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Olivera Ivanov
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Department for Radiation Oncology, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Martin Chorváth
- Department of Radiation Oncology, St. Elisabeth Cancer Institute, Slovak Medical University, Bratislava, Slovakia
| | - Andrea Ligačová
- Department of Radiation Oncology, St. Elisabeth Cancer Institute, Slovak Medical University, Bratislava, Slovakia
| | - András Csejtei
- Department of Oncoradiology, Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - Gabriella Gábor
- Oncoradiology Centre, Bács-Kiskun County Hospital, Kecskemét, Hungary
| | - László Landherr
- Municipal Oncoradiology Centre, Uzsoki Street Hospital, Budapest, Hungary
| | - László Mangel
- Oncotherapy Institute, University of Pécs, Pécs, Hungary
| | - Árpád Mayer
- Municipal Oncoradiology Centre, Uzsoki Street Hospital, Budapest, Hungary
| | - János Fodor
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
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Zhang L, Wang XZ, Li C, Yu Q, Liu Z, Yu ZY. Contralateral Axillary Lymph Node Metastasis of Breast Cancer: Retrospective Analysis and Literature Review. Front Oncol 2022; 12:869397. [PMID: 35494019 PMCID: PMC9047860 DOI: 10.3389/fonc.2022.869397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundContralateral axillary lymph node metastasis (CAM) is classified as distant metastasis in guidelines, but the prognosis is better than that of stage IV patients. It is controversial to classify CAM as a distant metastasis or a regional metastasis, and the optimal treatment strategy for CAM is unknown.Patients and MethodsBreast cancer patients who were confirmed by pathology and treated at Shandong Cancer Hospital between January 2012 and July 2021 were included in our study. We retrospectively reviewed the medical records of the patients for their clinical features, pathological diagnosis, treatment strategy, and follow-up data. Survival analysis was calculated by Kaplan–Meier analysis, and patient matching was performed by case–control matching.ResultsA total of 60 patients were included, and there were 49 metachronous CAM cases and 11 synchronous CAM cases. The prognosis of isolated CAM patients was better than that of patients with other distant metastases in terms of CAM-OS and PFS with significant differences (median CAM-OS 71.0 vs. 30.0 months, P=0.022; median PFS 42.0 vs. 11.0 months, P=0.009) and OS without significant differences (median OS 126.0 vs. 79.0 months, P=0.111). The five-year survival rate of isolated CAM patients was 67.4%, and the five-year disease-free survival (DFS) rate was 52.9%. The prognosis of CAM patients was similar to that of N3M0 patients in terms of OS (mean OS 82.4 vs. 65.6 months, P=0.537) and DFS (mean PFS 54.5 vs. 52.6 months, P=0.888). Axillary lymph node dissection (ALND) or low-middle level ALND significantly improved the OS (mean OS 237.4 vs. 111.0 months, P=0.011), CAM-OS (mean CAM-OS 105.2 vs. 46.6 months, P = 0.002), and PFS (mean PFS 92.3 vs. 26.9 months, P = 0.001) of isolated CAM patients. Axillary radiotherapy improved PFS, CAM-OS, and OS but without significant differences (mean PFS 80.0 vs. 46.6 months, P = 0.345; mean CAM-OS 86.8 vs. 72.1 months, P = 0.338; mean OS 147.6 vs. 133.0 months, P = 0.426).ConclusionCAM should be diagnosed as local recurrence and treated with aggressive and curative rather than palliative strategies. Contralateral axillary surgery and radiotherapy are recommended for isolated CAM patients.
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Affiliation(s)
- Liang Zhang
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xin zhao Wang
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Chao Li
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Qian Yu
- Interventional Radiology, University of Chicago, Chicago, IL, United States
| | - Zhaoyun Liu
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zhi yong Yu
- Department of Breast Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- *Correspondence: Zhi yong Yu,
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Lin H, Lin J, Wu Y, Liang G, Sun J, Chen L. Exploring the Prognosis of Breast Cancer with Synchronous Distant Nonregional Lymph Node Metastasis and Establishing a Predictive Model: A Population-Based Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5027457. [PMID: 35071594 PMCID: PMC8769852 DOI: 10.1155/2022/5027457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND We aimed to explore the prognosis of breast cancer patients with synchronous isolated distant-lymph node metastasis (SDLNM). METHODS We extracted information from the Surveillance, Epidemiology, and End Results Program. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS). Fine-Gray test was utilized to compare breast cancer-specific survival (BCSS). We applied propensity score matching (PSM) to balance confounders. In total, 692 SDLNM patients were allocated into training and validation cohorts. Univariate and multivariate analyses were implemented to determine independent prognostic variables. A nomogram predicting OS of SDLNM patients was constructed. Calibration curves and receiver operating characteristic curves were utilized to access the predictive model. RESULTS Cox regression and PSM analysis showed that the prognosis of SDLNM patients was similar to breast cancer patients in stage TnN3cM0 and superior to patients with other oligometastasis (SDLNM vs. TnN3cM0, p = 0.778; SDLNM vs. other oligometastasis: HR 0.767, 95% CI, 0.672-0.875, p < 0.001). A nomogram was established to predict 1-, 3-, and 5-year OS for SDLNM patients. All C-indexes and AUCs were greater than 0.7. Calibration curves implied accurate prediction. For patients receiving mastectomy, postoperative chemotherapy and radiotherapy were significant. CONCLUSIONS Breast cancer with SDLNM has a similar OS and BCSS with locally advanced disease. Comprehensive treatment was associated with better prognosis compared with palliative therapy. We constructed a predictive model for SDLNM breast cancer. It will be necessary to design large-scale prospective trials to confirm our results and validate the predictive model.
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Affiliation(s)
- Hong Lin
- Department of Medical Oncology, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jianxiong Lin
- Department of Hematology and Oncology, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Yanxuan Wu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Guoxi Liang
- Department of Oncology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jiating Sun
- Department of Oncology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Liming Chen
- Department of Oncology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Contemporary Outcomes After Multimodality Therapy in Patients With Breast Cancer Presenting With Ipsilateral Supraclavicular Node Involvement. Int J Radiat Oncol Biol Phys 2022; 112:66-74. [PMID: 34710521 PMCID: PMC8688264 DOI: 10.1016/j.ijrobp.2021.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Patients with breast cancer and ipsilateral supraclavicular (SCV) node involvement at the time of diagnosis (TNM cN3c) have historically had poor outcomes. Radiation therapy (RT) has an important role because SCV nodes are not routinely surgically dissected. However, optimal locoregional management, contemporary outcomes, and prognostic factors are not well defined. METHODS AND MATERIALS We reviewed the data of patients with cN3c breast cancer treated at our institution between 2014 and 2019 with curative intent, including neoadjuvant chemotherapy, surgery, and adjuvant RT. All patients received comprehensive regional RT, including to the SCV nodes. Institutional guidelines recommend a 10-Gy or 16-Gy boost to resolved and unresolved N3 nodes, respectively. Overall survival (OS), recurrence-free survival (RFS), locoregional recurrence-free survival (LRRFS), and supraclavicular recurrence-free survival (SCRFS) were analyzed. RESULTS Data from 173 consecutive patients were analyzed with a median follow-up time of 2.8 years. The median age was 54 years, 76 patients (44%) were estrogen receptor positive/human epidermal growth factor receptor 2 negative, 100 patients (58%) had T3/4 disease, and 10 patients (6%) underwent a neck dissection. In addition, 156 patients (90%) received a cumulative SCV dose of ≥60 Gy. The 5-year OS, SCRFS, LRRFS, and RFS rates were 73%, 95%, 86%, and 50%, respectively. The 5-year OS rate for a cumulative SCV dose of ≥60 Gy versus <60 Gy was 75% versus 39% (P = .04). In the multivariable analysis, a cumulative SCV dose of ≥60 Gy, extranodal extension, receptor status, and Eastern Cooperative Oncology Group performance status were associated with OS. The 5-year SCRFS rates with and without neck dissection were 100% versus 95% (P = .57). Among patients with a postchemotherapy SCV node size of ≥1 cm without neck dissection, the 5-year SCRFS rate was 83%. CONCLUSIONS In one of the largest series of patients with cN3c breast cancer, multimodality therapy using adjuvant RT with a SCV boost resulted in a 5-year LRRFS rate of 86%. There is a limited role for neck dissection as the 5-year SCRFS rate was 95% overall and 83% for residual SCV disease ≥1 cm after chemotherapy with RT alone. A cumulative SCV dose of ≥60 Gy was associated with improved OS, but not SCRFS, LRRFS, or RFS. A SCV boost should be considered in these patients as treatment was well-tolerated. Despite advances in systemic therapy, nearly half of patients developed distant metastases, highlighting the need for close observation after treatment.
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Long-Term Outcomes of Breast Cancer Patients Who Underwent Selective Neck Dissection for Metachronous Isolated Supraclavicular Nodal Metastasis. Cancers (Basel) 2021; 14:cancers14010164. [PMID: 35008328 PMCID: PMC8750885 DOI: 10.3390/cancers14010164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
We retrospectively enrolled 139 patients who developed metachronous isolated supraclavicular lymph node metastasis (miSLNM) from 8129 consecutive patients who underwent primary surgery between 1990 and 2008 at a single medical center. The median age was 47 years. The median follow-up time from date of primary tumor surgery was 73.1 months, and the median time to the date of neck relapse was 43.9 months in this study. Sixty-one (43.9%) patients underwent selective neck dissection (SND). The 5-year distant metastasis-free survival (DMFS), post-recurrence survival, and overall survival (OS) rates in the SND group were 31.1%, 40.3%, and 68.9%, respectively, whereas those of the no-SND group were 9.7%, 32.9%, and 57.7%, respectively (p = 0.001). No SND and time interval from primary tumor surgery to neck relapse ≤24 months were the only significant risk factors in the multivariate analysis of DMFS (hazard ratio (HR), 1.77; 95% confidence interval (CI), 1.23-2.56; p = 0.002 and HR, 1.76, 95% CI, 1.23-2.52; p = 0.002, respectively) and OS (HR, 1.77; 95% CI, 1.22-2.55; p = 0.003 and HR, 3.54, 95% CI, 2.44-5.16; p < 0.0001, respectively). Multimodal therapy, including neck dissection, significantly improved the DMFS and OS of miSLNM. Survival improvement after miSLNM control by intensive surgical treatment suggests that miSLNM is not distant metastasis.
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Development and validation of a nomogram for predicting survival of breast cancer patients with ipsilateral supraclavicular lymph node metastasis. Chin Med J (Engl) 2021; 134:2692-2699. [PMID: 34743149 PMCID: PMC8631408 DOI: 10.1097/cm9.0000000000001755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Breast cancer patients with ipsilateral supraclavicular lymph node metastasis (ISLNM) but without distant metastasis are considered to have a poor prognosis. This study aimed to develop a nomogram to predict the overall survival (OS) of breast cancer patients with ISLNM but without distant metastasis. Methods: Medical records of breast cancer patients who received surgical treatment at the Affiliated Cancer Hospital of Zhengzhou University, Jiyuan People's Hospital and Huaxian People's Hospital between December 21, 2012 and June 30, 2020 were reviewed retrospectively. Overall, 345 patients with pathologically confirmed ISLNM and without evidence of distant metastasis were identified. They were further randomized 2:1 and divided into training (n = 231) and validation (n = 114) cohorts. A nomogram to predict the probability of OS was constructed based on clinicopathologic variables identified by the univariable and multivariable analyses. The predictive accuracy and discriminative ability were measured by calibration plots, concordance index (C-index), and risk group stratification. Results: Univariable analysis showed that estrogen receptor-positive (ER+), progesterone receptor-positive (PR+), human epidermal growth factor receptor 2-positive (HER2+) with Herceptin treatment, and a low axillary lymph node ratio (ALNR) were prognostic factors for better OS. PR+, HER2+ with Herceptin treatment, and a low ALNR remained independent prognostic factors for better OS on multivariable analysis. These variables were incorporated into a nomogram to predict the 1-, 3-, and 5-year OS of breast cancer patients with ISLNM. The C-indexes of the nomogram were 0.737 (95% confidence interval [CI]: 0.660–0.813) and 0.759 (95% CI: 0.636–0.881) for the training and the validation cohorts, respectively. The calibration plots presented excellent agreement between the nomogram prediction and actual observation for 3 and 5 years, but not 1 year, OS in both the cohorts. The nomogram was also able to stratify patients into different risk groups. Conclusions: In this study, we established and validated a novel nomogram for predicting survival of patients with ISLNM. This nomogram may, to some extent, allow clinicians to more accurately estimate prognosis and to make personalized therapeutic decisions for individual patients with ISLNM.
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Zhang XF, Zhang Y, Liang XW, Chen JL, Zhi SF, Yin WJ, Wang MY, Dong EL, Chen DP. Subphrenic Lymph Node Metastasis Predicts Poorer Prognosis for Nasopharyngeal Carcinoma Patients With Metachronous Metastasis. Front Oncol 2021; 11:726179. [PMID: 34660291 PMCID: PMC8517449 DOI: 10.3389/fonc.2021.726179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/25/2021] [Indexed: 11/13/2022] Open
Abstract
Aim We retrospectively analyzed the distribution of distant lymph node metastasis and its impact on prognosis in patients with metastatic NPC after treatment. Methods From 2010 to 2016, 219 NPC patients out of 1,601 (182 from the Affiliated Cancer Hospital and Institute of Guangzhou Medical University, and 37 from the Affiliated Dongguan Hospital, Southern Medical University) developed distant metastasis after primary radiation therapy. Metastatic lesions were divided into groups according to location: bones above the diaphragm (supraphrenic bone, SUP-B); bones below the diaphragm (subphrenic bone, SUB-B); distant lymph nodes above the diaphragm (supraphrenic distant lymph nodes, SUP-DLN); distant lymph nodes below the diaphragm (subphrenic distant lymph nodes, SUB-DLN), liver, lung, and other lesions beyond bone/lung/distant lymph node above the diaphragm (supraphrenic other lesions, SUP-OL); other lesions beyond bone/liver/distant lymph node below the diaphragm (subphrenic other lesions, SUB-OL); the subtotal above the diaphragm (supraphrenic total lesions, SUP-TL); and the subtotal below the diaphragm (subphrenic total lesions, SUB-TL). Kaplan–Meier methods were used to estimate the probability of patients’ overall survival (OS). Univariate and multivariate analyses were applied using the Cox proportional hazard model to explore prediction factors of OS. Results The most frequent metastatic locations were bone (45.2%), lung (40.6%), liver (32.0%), and distant lymph nodes (20.1%). The total number of distant lymph node metastasis was 44, of which 22 (10.0%) were above the diaphragm, 18 (8.2%) were below the diaphragm, and 4 (1.8%) were both above and below the diaphragm. Age (HR: 1.02, 95% CI: 1.00, 1.03, p = 0.012), N stage (HR: 1.26, 95% CI: 1.04, 1.54, p = 0.019), number of metastatic locations (HR: 1.39, 95% CI: 1.12, 1.73, p = 0.003), bone (HR: 1.65, 95% CI: 1.20, 2.25, p = 0.002), SUB-B (HR: 1.51, 95% CI: 1.07, 2.12, p = 0.019), SUB-DLN (HR: 1.72, 95% CI: 1.03, 2.86, p = 0.038), and SUB-O L(HR: 4.46, 95% CI: 1.39, 14.3, p = 0.012) were associated with OS. Multivariate analyses revealed that a higher N stage (HR: 1.23, 95% CI: 1.00, 1.50, p = 0.048), SUB-DLN (HR: 1.72, 95% CI: 1.02, 2.90, p = 0.043), and SUB-OL (HR: 3.72, 95% CI: 1.14, 12.16, p = 0.029) were associated with worse OS. Conclusion Subphrenic lymph node metastasis predicts poorer prognosis for NPC patients with metachronous metastasis; however, this needs validation by large prospective studies.
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Affiliation(s)
- Xue-Fang Zhang
- Radiotherapy Department, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, China
| | - Yan Zhang
- Radiotherapy Department, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, China
| | - Xu-Wei Liang
- Radiotherapy Department, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, China
| | - Jia-Luo Chen
- Radiotherapy Department, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, China
| | - Sheng-Fang Zhi
- Nuclear Medicine Department, Affiliated Dongguan Hospital, Southern Medical University, Dongguan, China
| | - Wen-Jing Yin
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Meng-Yao Wang
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - En-Lai Dong
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
| | - Dong-Ping Chen
- Department of Radiation Oncology, Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, China
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Kolben T, Beyer S, Ghasemi S, Hermelink K, Meister S, Degenhardt T, Himsl I, Edler von Koch F, Kolben TM, Wuerstlein R, Mahner S, Harbeck N, Hester A. Late Presentation at Primary Diagnosis of Breast Cancer: Patients' Personality Characteristics and Attitudes. Breast Care (Basel) 2021; 16:343-349. [PMID: 34602939 DOI: 10.1159/000509597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 06/23/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Breast cancer (BC) is the most common cancer in women worldwide. Despite screening and information efforts, about 10% of patients present with tumor size T3 or T4 at primary diagnosis. Late presentation is associated with more advanced tumor stage and consecutively with worse survival rates. Objective This study aimed to evaluate whether patients with a late presentation at primary BC diagnosis differ in their personality from those with early diagnosis. Methods In this bicentric, observational study, personality traits, positive and negative affectivity, anxiety, spirituality, illness beliefs, and sociodemographic characteristics were assessed in BC patients who presented with T-stages 3 or 4 (late presenters) and T-stages 1 or 2 (controls) at initial diagnosis. Results Forty patients (20 controls, 20 late presenters) were interviewed. "Late presenters" perceived their disease as long lasting and had significantly more "positive affectivity" in the current trait. Although no significant associations were found, there was a trend for late presenters to have higher education levels, less spiritual longing, less accurate explanation of their illness, less anxiety in the trait scale, and more conscientiousness than the controls. Conclusion As patients with late presentation for BC differ in specific psychological and sociodemographic characteristics from patients with early BC, the findings of this pilot project warrant additional investigations to identify further specific characteristics and motivations. Identifying patients at risk for late presentation and encouraging them to accept an earlier diagnosis could help to improve their therapy and, finally, their outcome.
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Affiliation(s)
- Thomas Kolben
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Susanne Beyer
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Sanaz Ghasemi
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Kerstin Hermelink
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Sarah Meister
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Tom Degenhardt
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Isabelle Himsl
- Department of Obstetrics and Gynecology, Klinikum Dritter Orden, Munich, Germany
| | - Franz Edler von Koch
- Department of Obstetrics and Gynecology, Klinikum Dritter Orden, Munich, Germany
| | - Theresa M Kolben
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Rachel Wuerstlein
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Nadia Harbeck
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
| | - Anna Hester
- Department of Obstetrics and Gynecology, Breast Center and CCC LMU University Hospital, LMU Munich, Munich, Germany
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Chung HL, Le-Petross HT, Leung JWT. Imaging Updates to Breast Cancer Lymph Node Management. Radiographics 2021; 41:1283-1299. [PMID: 34469221 DOI: 10.1148/rg.2021210053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Metastatic lymph node involvement in breast cancer is a key determinant of the overall stage of disease and prognosis. Historically, lymph node status was determined by surgery first, with adjuvant treatments determined based on the results of the final surgical pathologic analysis. While this sequence is still applicable in many cases, neoadjuvant systemic treatment (NST) is increasingly being administered as the initial treatment. In cases that demonstrate good therapeutic response to drug therapies, NST may permit the option to perform less radical surgeries subsequently. Current breast cancer treatment has become multidisciplinary, with overlapping roles from the different disciplines. As surgery may be postponed, imaging and image-guided lymph node interventions have gained importance as the primary means of lymph node assessment. Imaging enables evaluation of all regional nodal basins, including locations where surgery is not usually performed. By differentiating limited versus extensive nodal involvement, imaging findings help determine whether initial treatment should be surgical or medical. If medical treatment with NST is indicated, imaging is performed to monitor the in vivo nodal response to drug therapy and ultimately to help determine the surgical technique to perform on the basis of the final imaging findings after NST. The authors discuss the imaging features of nodal metastases and the indications and techniques for the various image-guided procedures. The relative usefulness and shortcomings of the various imaging examinations are reviewed to discuss how they can be applied when biopsy results are not available. The role of imaging in the multidisciplinary team approach is emphasized based on past clinical trials of lymph node management and recent evolving knowledge of breast cancer staging. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Hannah L Chung
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Huong T Le-Petross
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
| | - Jessica W T Leung
- From the Department of Breast Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030
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Jin K, Luo J, Wang X, Yang Z, Zhang L, Mei X, Ma J, Chen X, Zhang X, Zhou Z, Wang X, Shao Z, Zhang Z, Guo X, Yu X. Symptoms Related to Brachial Plexus Neuropathy After Supraclavicular Irradiation and Boost in Breast Cancer. Pract Radiat Oncol 2021; 12:e13-e23. [PMID: 34450336 DOI: 10.1016/j.prro.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the incidence of symptoms related to brachial plexus neuropathy (BPN) and the dose distribution to the brachial plexus (BP) in patients with breast cancertreated with supraclavicular (SCV) irradiation and boost. METHODS AND MATERIALS In this study, 117 patients with initial ipsilateral supraclavicular lymph node (SLN) metastasis and 39 with recurrent SLN metastasis between 2008 and 2018 in our cancer center were retrospectively analyzed. All patients were treated with 50 Gy of SCV irradiation in 25 fractions and a boost (median dose, 10 Gy; range, 10-16 Gy) to involved nodes in the SCV area. Symptoms related to BPN (including ipsilateral arm numbness, pain, and weakness) were recorded and graded according to the Common Terminology Criteria for Adverse Events, version 5.0. The BP was delineated on simulation computed tomography, and the dose distributions to the BP were evaluated. Meanwhile, 297 patients treated with SCV irradiation without boost during the same period were identified as a control group to compare the incidences of BPN-related symptoms and dosimetric data with patients who received an SCV boost. RESULTS The 5-year overall survival rate was 80.3% for patients with initial SLN metastasis and 51.0% for patients with recurrent SLN metastasis. For patients who received an SCV boost, incidence rates of ipsilateral arm numbness, pain, and weakness were 23.9%, 18.3%, and 34.3%, respectively. Four patients (5.6%) developed grade 2 numbness and 3 (4.3%) developed grade 2 arm weakness. In the control group, incidence rates of arm numbness, pain, and weakness were 31.6%, 21.9%, and 36.0%, respectively. The incidence of BPN-related symptoms was not significantly different between the 2 groups. Symptoms of grade 3 were not observed in either cohort. The mean doses to the BP in patients who received boost and who did not were 56.8 and 46.8 Gy, respectively (P < .001). The maximum doses to the BP in patients who received boost and who did not were 64.5 and 53.5 Gy, respectively (P < .001). The BP volumes receiving at least 50 Gy, 60 Gy, 61 Gy, and 62 Gy were also significantly higher in the boosted group compared with the control group (P < .001). CONCLUSIONS This study found that an SCV boost of 10 Gy did not increase the incidence of BPN-related symptoms and that the toxicity to the BP was acceptable. Comprehensive treatment including SCV irradiation and boost led to satisfactory survival outcomes in patients with breast cancer who had SLN metastasis.
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Affiliation(s)
- Kairui Jin
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jurui Luo
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xuanyi Wang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhaozhi Yang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li Zhang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin Mei
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jinli Ma
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xingxing Chen
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiaomeng Zhang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhirui Zhou
- Radiation Oncology Center, Huanshan Hospital
| | - Xiaofang Wang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center; Department of Breast Surgery, Fudan University Shanghai Cancer Center
| | - Zhen Zhang
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiaomao Guo
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Xiaoli Yu
- Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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Breast Cancer Skip Metastases: Frequency, Associated Tumor Characteristics, and Role of Staging Nodal Ultrasound in Detection. AJR Am J Roentgenol 2021; 217:835-844. [PMID: 32997506 DOI: 10.2214/ajr.20.24371] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND. Staging nodal ultrasound (US) evaluates locations beyond those assessed during routine surgical dissection and has an increasing role in breast cancer management given the growing use of neoadjuvant systemic therapy before surgical staging. OBJECTIVE. The purpose of this study is to identify the patterns of nodal spread of breast cancer observed at staging nodal US and to determine the frequency of skip metastases and associated tumor characteristics. METHODS. This retrospective study included 1269 consecutive patients (31 with bilateral synchronous cancers) who had 1300 newly diagnosed, untreated, invasive breast cancers and underwent US examination of the ipsilateral regional nodal basins from January 2016 through March 2017. Cases with suspicious nodes on US underwent fine-needle aspiration (FNA) biopsy. Cases with benign results on FNA and no suspicious nodes on US underwent sentinel lymph node biopsy. Results of US with FNA were compared with final surgical pathology. Skip metastases were defined as spread across discontiguous nodal levels or distant metastases in the absence of ipsilateral nodal metastases. The incidence and patterns of spread of skip metastases were summarized; associations with tumor characteristics were tested using the Fisher exact test. RESULTS. A total of 591 metastatic cases (45.5%) were confirmed by needle biopsy or sentinel lymph node biopsy, comprising 463 nodal metastases (N+) confirmed by FNA, 121 nodal metastases (N+) confirmed by sentinel lymph node biopsy, and seven distant organ metastases without nodal metastases (N0M1) confirmed by CT-guided biopsy. US with FNA had sensitivity of 86.0%, specificity of 100.0%, PPV of 100.0%, NPV of 89.5%, and accuracy of 93.6%. There were 34 skip metastases, for an incidence of 2.6% (34/1300) (95% CI, 1.8-3.6%) among all invasive cancers and 7.2% (34/470) (95% CI, 5.1-9.9%) among metastatic cancers detected by US and FNA. Skip metastases occurred to axillary level III (n = 4), the supraclavicular nodal basin (n = 21), the contralateral axilla (n = 2), and distant organs (n = 7). Cancers with skip metastases, compared with those with nonskip metastases, had higher rates (p = .005) of lobular histology (23.5% vs 6.7%) and mixed ductal and lobular histology (11.8% vs 6.7%). Skip metastases were not associated with grade, T category, or molecular subtype (p > .05). CONCLUSION. Skip metastases to locations beyond standard surgical axillary dissection occur in 7.2% of metastatic breast cancers. CLINICAL IMPACT. Staging nodal US identifies skip metastases that otherwise would be undetected, helping to achieve more accurate staging and minimize undertreatment.
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22
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Nash AL, Thomas SM, Plichta JK, Fayanju OM, Hwang ES, Greenup RA, Rosenberger LH. Contralateral Axillary Nodal Metastases: Stage IV Disease or a Manifestation of Progressive Locally Advanced Breast Cancer? Ann Surg Oncol 2021; 28:5544-5552. [PMID: 34287787 DOI: 10.1245/s10434-021-10461-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contralateral axillary nodal metastases (CAM) is classified as stage IV disease, although many centers treat CAM with curative intent. We hypothesized that patients with CAM, treated with multimodality therapy, would have improved overall survival (OS) versus patients with distant metastatic disease (M1) and similar OS to those with locally advanced breast cancer (LABC). METHODS Using the NCDB (2004-2016), we categorized adult patients with node-positive breast cancer into three study groups: LABC, CAM, and M1. Kaplan-Meier curves were used to visualize the unadjusted OS. Cox proportional hazards models were used to estimate the association of study group with OS. RESULTS A total of 94,487 patients were identified: 122 with CAM, 12,325 with LABC, and 82,040 with M1 (median follow-up 63.6 months). LABC and CAM patients had similar histology and rates of chemotherapy and endocrine therapy receipt. However, the CAM group had significantly larger tumors, more estrogen-receptor expression, higher T-stage, and more mastectomies than the LABC group. Compared with M1 patients, CAM patients were more likely to have grade 3 and cT4 tumors. Patients with CAM and LABC had similar 5-year unadjusted OS and significantly improved OS vs M1 patients. After adjustment, LABC and CAM patients continued to have similar OS and better OS vs M1 patients. CONCLUSIONS CAM patients who receive multi-modal therapy with curative intent may have OS more comparable to LABC patients than M1 patients. Out data support a reevaluation of whether CAM should remain classified as M1, as N3 may better reflect disease prognosis and treatment goals.
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Affiliation(s)
- Amanda L Nash
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, NC, USA.,Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Rachel A Greenup
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, NC, USA. .,Duke Cancer Institute, Duke University, Durham, NC, USA.
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23
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Extra-axillary nodal metastases in breast cancer: comparison of ultrasound, MRI, PET/CT, and CT. Clin Imaging 2021; 79:113-118. [PMID: 33933824 DOI: 10.1016/j.clinimag.2021.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/15/2021] [Accepted: 03/19/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate how ultrasound (US), MRI, PET/CT, and CT predict extra-axillary nodal metastases. SUBJECTS AND METHODS This IRB approved, retrospective study consisted of 124 suspicious supraclavicular and 88 internal mammary (IM) nodal cases with US and at least one additional cross-sectional examination (MRI, PET/CT or CT) from a total of 1472 invasive cancers with staging nodal US between January 2016-January 2019. Imaging findings were compared with the true node status, determined by fine needle aspirate (FNA) biopsy or evidence of response to chemotherapy on follow up imaging. RESULTS In the supraclavicular region, US had accuracy 98.2%, consisting of 97 true positives (TP), 27 false positives (FP), and 1348 true negative (TN). 93.5% of suspicious supraclavicular nodes had FNA for a PPV 78.2%. PET/CT had accuracy 88.6% (26 TP, 5 TN and 4 false negatives (FN)). CT exams had accuracy 61.7% (42 TP, 16 TN, 7 FP, and 29 FN). In the IM region, US had accuracy 93.2% (82 TP, 1 FP, 5 FN, and 1384 TN) but only 43.2% of suspicious IM nodes had FNA for a PPV 98.8%. MRI had accuracy 100.0% (all 47 TP). PET/CT exams had accuracy 96.8% (30 TP and 1FN). CT exams had accuracy 62.7% (36 TP, 1 TN, and 22 FN). CONCLUSION US/FNA has accuracy 98.2% and 93.2% in the supraclavicular and IM regions, however only 43.2% of suspicious IM nodes are directly sampled. In these cases, MRI or PET/CT can be used to problem solve and guide treatment decisions.
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24
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Zou Y, Hu X, Deng X. Distant Lymph Node Metastases From Breast Cancer-Is it Time to Review TNM Cancer Staging? JAMA Netw Open 2021; 4:e212026. [PMID: 33724385 DOI: 10.1001/jamanetworkopen.2021.2026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yutian Zou
- Department of Breast Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xiaoqian Hu
- School of Biomedical Sciences, Faculty of Medicine, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Xinpei Deng
- School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
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25
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Pan H, Wang H, Qian M, Mao X, Shi G, Ma G, Yu M, Xie H, Ling L, Ding Q, Zhang K, Wang S, Zhou W. Comparison of Survival Outcomes Among Patients With Breast Cancer With Distant vs Ipsilateral Supraclavicular Lymph Node Metastases. JAMA Netw Open 2021; 4:e211809. [PMID: 33724394 PMCID: PMC7967083 DOI: 10.1001/jamanetworkopen.2021.1809] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE There is a lack of studies exploring whether the survival of patients with distant lymph node metastases (DLNM) is different from that of patients with ipsilateral supraclavicular lymph node metastases (ISLM) and other stage IV breast cancer. OBJECTIVE To assess the survival of patients with DLNM from breast cancer vs ISLM and other stage IV breast cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 2033 patients diagnosed with breast cancer between January 1, 2010, and December 31, 2014, from the Surveillance, Epidemiology and End Results registries database. Three groups of patients were included: (1) patients with ISLM without any distant metastasis, (2) patients with DLNM, and (3) patients with distant metastases (DLNM excluded). Patients younger than 18 years or older than 100 years were excluded. The data were analyzed in February 2020. EXPOSURES Surgery for primary tumor, surgery for distant lymph nodes, and radiotherapy. MAIN OUTCOMES AND MEASURES Overall survival (OS) and breast cancer-specific survival (BCSS). RESULTS Of the 2033 women (mean [SD] age, 62.03 [14.62] years [range, 23.00-99.00 years]; 1510 White participants [74.3%]) with breast cancer included in the study, 346 patients (17.0%) had DLNM, 212 (10.4%) had ISLM, and 1475 (72.6%) had distant metastases (DLNM excluded). The 3-year BCSS rates were 63.24% for ISLM, 64.54% for DLNM, and 41.20% for distant metastases. The 3-year OS rates were 53.46% for ISLM, 62.67% for DLNM, and 38.21% for distant metastases. Compared with patients with ISLM, patients with DLNM showed similar BCSS (hazard ratio [HR], 0.81; 95% CI, 0.52-1.25; P = .34) and OS (HR, 0.73; 95% CI, 0.51-1.05; P = .09), whereas patients with distant metastases showed significantly poorer BCSS (HR, 1.99; 95% CI, 1.43-2.78; P < .001) and OS (HR, 1.79; 95% CI, 1.35-2.38; P < .001). Of the 346 patients with DLNM, primary surgery (HR, 0.21; 95% CI, 0.12-0.39; P < .001) and radiotherapy (HR, 0.46; 95% CI, 0.25-0.87; P = .02) were significantly associated with improved OS. CONCLUSIONS AND RELEVANCE The results of this cohort study suggest that DLNM of breast cancer, with similar survival to N3c disease (indicating metastases to the ipsilateral supraclavicular lymph nodes), might be a regional disease, and reassessment of the role of lymph node metastases in breast cancer may be necessary. Given these findings, aggressive locoregional therapies for this disease are recommended, although future studies are still needed to confirm these results.
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Affiliation(s)
- Hong Pan
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hui Wang
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Mengjia Qian
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xinrui Mao
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Guojian Shi
- Department of Thyroid and Breast Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Thyroid and Breast Surgery, The Second People’s Hospital of Kunshan, Suzhou, China
| | - Ge Ma
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Muxin Yu
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hui Xie
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lijun Ling
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Qiang Ding
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Kai Zhang
- Pancreatic Center & Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China
- Pancreas Institute of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Shui Wang
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Wenbin Zhou
- Department of Breast Surgery, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Jiangsu Collaborative Innovation Center for Cancer Personalized Medicine, School of Public Health, Nanjing Medical University, Nanjing, China
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Lv M, Li J, Guo H, Wang C, Tian P, Ma Y, Chen X, Luo S. Impact of Ipsilateral Supraclavicular Lymph Node Dissection (ISLND) for Breast Cancer Patients and a Nomogram for Predicting Ipsilateral Supraclavicular Pathological Complete Response (ispCR). Ann Surg Oncol 2021; 28:5098-5109. [PMID: 33598861 DOI: 10.1245/s10434-020-09548-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the impact of ipsilateral supraclavicular lymph node dissection (ISLND) on the outcomes of breast cancer patients with ipsilateral supraclavicular lymph node metastasis (ISLNM), and to evaluate the prognostic value of ipsilateral supraclavicular pathological complete response (ispCR). Meanwhile, a nomogram was constructed to predict ispCR. METHODS We retrospectively reviewed the medical documents of 353 patients with ISLNM but no distant metastasis at presentation. Based on whether ISLND was performed, patients were divided into radiotherapy (RT) and ISLND + RT groups. The impact of ISLND was evaluated after propensity score matching, and the prognostic value of ispCR was also analyzed. A nomogram to predict the probability of ispCR was constructed based on clinicopathologic variables. RESULTS After propensity score matching, we found that the use of ISLND was associated with a higher rate of ipsilateral supraclavicular relapse-free survival (ISRFS; p < 0.0001). Among 307 patients who underwent ISLND, ispCR was associated with a higher rate of ISRFS and disease-free survival (p = 0.018 and p = 0.00033, respectively). Furthermore, the nomogram constructed with number of axillary lymph node metastases, breast pCR, size of the ipsilateral supraclavicular lymph nodes after neoadjuvant chemotherapy (NAC), number of NAC cycles, and Ki67 level showed a good fit for predicting ispCR. CONCLUSION For breast cancer patients with ISLNM but no distant metastasis, ISLND may be beneficial in some certain subtypes, and ispCR indicated a better prognosis. Our nomogram is well-fitted to predict the probability of achieving ispCR.
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Affiliation(s)
- Minhao Lv
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Juntao Li
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Huihui Guo
- Department of General Surgery, Jiyuan People's Hospital, Jiyuan, China
| | - Chao Wang
- Department of General Surgery, Huaxian People's Hospital, Huaxian, China
| | - Peiqi Tian
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Youzhao Ma
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Xiuchun Chen
- Department of Breast Disease, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Suxia Luo
- Department of Medical Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China.
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Ma T, Mao Y, Wang H. Combined Therapy Can Improve the Outcomes of Breast Cancer with Isolated Supraclavicular Lymph Node Involvement. Cancer Manag Res 2020; 12:11857-11869. [PMID: 33239916 PMCID: PMC7682445 DOI: 10.2147/cmar.s276996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose This study aimed to evaluate the efficacy of systemic combined with local therapies in isolated metachronous ipsilateral supraclavicular lymph node metastasis (mISLM) breast cancer patients. Patients and Methods We reviewed the data of mISLM patients admitted by Breast Disease Center of the Affiliated Hospital of Qingdao University, from January 2009 to July 2019. Ninety-nine patients were included and were divided into two groups: the systemic group, which referred to patients who received only systemic therapy, and the combined group, which referred to patients who received systemic therapy plus local therapy (including neck radiotherapy (RT) and/or supraclavicular lymph node dissection surgery). In the combined group, patients were further divided into systemic therapy plus: 1) neck RT, 2) supraclavicular lymph node dissection surgery, and 3) neck RT and supraclavicular lymph node dissection surgery. Results The median duration of follow-up was 36 months. The median PFS was 15 months, and the median OS was 35 months. Local control rates of 1 year, 2 years and 3 years were 92.9%, 86.9% and 84.8%, respectively. The combined group (n=56) had a significantly better PFS (P<0.001) and OS (P=0.001) than the systemic group (n=43). Compared with Group B (n=13) and Group C (n=14), Group A (n=29) had a significantly better PFS (P=0.007). Higher dose and conventional dose showed no significant differences regarding the local control rate (P=1.000), PFS (P=0.787) or OS (P=0.690) in the patients who received RT. In multivariate analysis, pN3 stage and combined therapy (systemic therapy plus local therapy) for mISLM affected PFS (P<0.001 and P=0.002, respectively). Neck RT was an independent parameter affecting OS (P=0.002). Conclusion In breast cancer patients with mISLM, systemic therapy combined with local therapy could improve PFS and OS. Based on systemic therapy, RT had a better effect on survival than surgery. However, more aggressive methods, such as systemic therapy combined with both RT and surgery or a higher dose of RT, may not be associated with improved PFS or OS in these patients.
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Affiliation(s)
- Tianyi Ma
- Department of Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Yan Mao
- Department of Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Haibo Wang
- Department of Breast Disease Center, The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
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Liu S, Fang J, Jiao D, Liu Z. The predictive value of inflammatory markers for pathological response of ipsilateral supraclavicular lymph nodes and for prognosis in breast cancer after neoadjuvant chemotherapy. Gland Surg 2020; 9:1354-1362. [PMID: 33224810 DOI: 10.21037/gs-20-341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Inflammatory tumor microenvironment is closely related to cancer. In this study, we mainly explore the predictive value of inflammatory markers for pathological response of ipsilateral supraclavicular lymph nodes (ISLN) and for prognosis in breast cancer with ISLN metastasis after neoadjuvant chemotherapy (NAC). Methods In this study, 117 breast cancer patients with ISLN metastasis were collected from the Affiliated Hospital of Zhengzhou University. The best cut-off value was determined by using the receiver operating characteristics (ROC) curve. Chi-square test and binary Logistic regression were used to analyze the correlation between clinical pathological data and pathological response of ISLN and to determine independent predictors. Correlation analysis between inflammatory markers and prognosis used time-dependent COX regression. Results The pathological complete response (pCR) rate of ISLN after NAC was 64.4%. Multivariate analysis showed that breast pCR (OR 9.67, 95% CI: 2.64-35.31, P<0.01) was an independent predictor of ISLN pathological response after NAC. After a median follow-up of 25 months, multivariate time-dependent COX results showed that higher platelet levels were correlated with poor disease-free survival (DFS) (HR 1.008, 95% CI: 1.001-1.015, P=0.028). Meanwhile, menopausal status (HR 0.35, 95% CI: 0.15-0.79, P=0.01) and supraclavicular pCR (HR 0.33, 95% CI: 0.15-0.77, P=0.01) were also independent predictors of DFS. Conclusions Peripheral blood inflammatory markers have limited predictive value for pathological response of ISLN after NAC for breast cancer. High platelet count is associated with poor prognosis of breast cancer patients with ISLN metastasis.
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Affiliation(s)
- Shaoqing Liu
- Department of Breast surgery, Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Fang
- Department of Breast surgery, Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Dechuang Jiao
- Department of Breast surgery, Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhenzhen Liu
- Department of Breast surgery, Breast Cancer Center, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
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29
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Sun XF, Wang YJ, Huang T, Niu LJ, Zhang Q, Liu ZZ. Comparison between surgery plus radiotherapy and radiotherapy alone in treating breast cancer patients with ipsilateral supraclavicular lymph node metastasis. Gland Surg 2020; 9:1513-1520. [PMID: 33224826 DOI: 10.21037/gs-20-691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Ipsilateral supraclavicular lymph node metastasis (ISLM) with breast cancer patients has always been a hard problem for breast surgery. It is generally believed that radiotherapy can benefit the survival of patients, but whether local surgical resection is needed or not is controversial. The study aims to compare the efficacy between supraclavicular lymph node (SLN) dissection combined with radiotherapy and radiotherapy alone in the treatment of breast cancer with ISLM. Methods A retrospective analysis was performed using 122 cases of breast cancer with ISLM but without distant metastasis. Among them, 14 cases were eliminated due to insufficient data. The 108 remaining cases were divided into 2 groups based on different treatment proposals for metastatic SLNs. The groups were dissection plus radiotherapy (surgery group), and simple radiotherapy (radiotherapy group). Results For the 108 patients, the overall 5-year disease-free survival (DFS) and overall survival (OS) rates were 30.6% and 67.8%, respectively. In the surgery group, distant metastases occurred in 41 patients, and the 5-year DFS was 34.3%; in the radiotherapy group, 18 patients had distant metastases, and the 5-year DFS was 26.1%; the difference was not statistically significant (P>0.05). In the surgery group, 11 patients died, and the 5-year OS rate was 67.9%; in the radiotherapy group, 6 patients died, and the 5-year OS rate was 67.5%; the difference was not statistically significant (P>0.05). Conclusions The dissection of SLN combined with radiotherapy and radiotherapy alone had similar effects on the survival rates in breast cancer patients with ISLM. The local control in the surgery group was better than that in the radiotherapy group. The status of estrogen receptors (ER) and the number of axillary lymph node metastases were independent influencing factors of DFS. The ER status is an independent factor affecting the OS rate of patients.
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Affiliation(s)
- Xian-Fu Sun
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Ying-Jie Wang
- Department of Oncology, Affiliated Zhengzhou Cancer Hospital of Henan University, Zhengzhou Cancer Hospital, Zhengzhou, China
| | - Tao Huang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Lian-Jie Niu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Qiang Zhang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Zhen-Zhen Liu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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Kunnuru SKR, Thiyagarajan M, Martin Daniel J, Singh K B. A Study on Clinical and Pathological Responses to Neoadjuvant Chemotherapy in Breast Carcinoma. BREAST CANCER-TARGETS AND THERAPY 2020; 12:259-266. [PMID: 33262647 PMCID: PMC7686913 DOI: 10.2147/bctt.s277588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
Aim and objectives To assess the effectiveness of neo-adjuvant chemotherapy and its impact on the clinical and pathological response in locally advanced breast cancer. To compare molecular subtypes of breast cancer with response to neo-adjuvant chemotherapy. Patients and methods This was a prospective study on patients who received neoadjuvant chemotherapy for breast carcinoma for a 3-year period. A total of 60 patients who presented with locally advanced breast cancer (LABC) were treated with neoadjuvant chemotherapy. Forty patients were treated with the 5-fluorouracil, epirubicin, and cyclophosphamide (FEC) schedule, 16 patients were treated with Adriamycin and cyclophosphamide (AC), and four patients were treated with oral cyclophosphamide, intravenous methotrexate, and fluorouracil (CMF). Taxol was added in all node-positive cases, triple negative breast cancer (TNBC), and Her 2 positive cases. The clinical response was assessed with RECIST criteria after neoadjuvant chemotherapy. The response was compared with molecular subtypes of carcinoma breast and receptor status individually. Results A total of 60 female patients receiving primary chemotherapy for locally advanced breast malignancy were studied. The median age of the patients at the time of diagnosis was 44 years (range=24–73). In terms of menopausal status, 25 (42%) patients were pre-menopausal and 35 (58%) patients were post-menopausal. Histological classification showed invasive ductal carcinoma in 72% of patients, invasive lobular carcinoma in 15% of patients, and other types including mixed patterns in 13% of patients. Among 60 patients, 16 patients (26.6%) had clinically complete remission (cCR), 30 patients (50%) had partial remission, eight patients (13.3%) had stable disease, and six patients (10%) had progressive disease. Following neoadjuvant chemotherapy, 46 (76.6%) patient underwent Modified radical mastectomy surgery. Target therapy was given for Her2 neu patients after surgery. Hormonal therapy was added to hormone ER PR positive cases postoperatively. Eight patients (13.3%) among this operated cases attained complete pathological response. Conclusion Preoperative chemotherapy downstages the primary tumors and axillary metastasis in patients with locally advanced breast carcinoma. Comparison of molecular subtypes with chemotherapy response is a better way to find out the predictors of response to chemotherapy.
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Affiliation(s)
| | | | - Jovita Martin Daniel
- Medical Oncology Department, Sri Ramachandra Medical University, Chennai 600116, India
| | - Balaji Singh K
- General Surgery Department, Sri Ramachandra Medical University, Chennai 600116, India
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Tamirisa NP, Ren Y, Campbell BM, Thomas SM, Fayanju OM, Plichta JK, Rosenberger LH, Force J, Hyslop T, Hwang ES, Greenup RA. Treatment Patterns and Outcomes of Women with Breast Cancer and Supraclavicular Nodal Metastases. Ann Surg Oncol 2020; 28:2146-2154. [PMID: 32946012 DOI: 10.1245/s10434-020-09024-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/25/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND In 2002, breast cancer patients with supraclavicular nodal metastases (cN3c) were downstaged from AJCC stage IV to IIIc, prompting management with locoregional treatment. We sought to estimate the impact of multimodal therapy on overall survival (OS) in a contemporary cohort of cN3c patients. METHODS Women ≥ 18 years with cT1-T4c/cN3c invasive breast cancer who underwent systemic therapy were identified from the 2004-2016 National Cancer Database. We compared three patient cohorts: (a) cN3c + multimodal therapy (systemic therapy, surgery, and radiation); (b) cN3c + non-standard therapy; and, (c) cM1. Logistic regression identified factors associated with receipt of multimodal therapy and Kaplan-Meier was used to estimate unadjusted OS. The Cox proportional hazards model estimated effects of diagnosis and treatment on OS after adjustment. RESULTS Overall, 1827 (3.7%) patients with cN3c disease and 46,919 (96.3%) cM1 patients were identified. Of cN3c patients, 74.5% (n = 1362) received multimodal therapy and 25.5% (n = 465) received non-standard therapy; receipt of multimodal therapy was associated with improved 5-year OS (multimodal: 59% vs. M1: 28% vs. non-standard: 28%, log-rank p < 0.001). Adjusting for covariates, non-standard therapy was associated with an increased risk of death compared with receipt of multimodal therapy (HR 2.20, 95% CI 1.71-2.83, p < 0.001). Private insurance was the only patient characteristic associated with a greater likelihood of receiving multimodal therapy (OR 2.81; 95% CI, 1.64-4.82; p < 0.001). CONCLUSION Women with cN3c breast cancer who received multimodal therapy demonstrated improved overall survival when compared with patients undergoing non-standard therapy and those with metastatic (M1) disease. Although selection bias may contribute to worse overall survival among cN3c patients undergoing non-standard therapy, national guidelines should encourage locoregional treatment in carefully selected patients.
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Affiliation(s)
- Nina P Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi Ren
- Duke Cancer Institute, Durham, NC, USA
| | | | | | - Oluwadamilola M Fayanju
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer K Plichta
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Laura H Rosenberger
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jeremy Force
- Duke Cancer Institute, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Terry Hyslop
- Duke Cancer Institute, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - E Shelley Hwang
- Duke Cancer Institute, Durham, NC, USA.,Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Rachel A Greenup
- Duke Cancer Institute, Durham, NC, USA. .,Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Chilwesa PM, Gameldien R, Steyn R, More S, Malherbe F, Human G, Mottay L, Moxley K, Hardy A, Anderson D, Hunter AJ, Parkes J. Comparison of 18F-Fluorodeoxyglucose positron emission tomography/computed tomography and conventional imaging for locally advanced breast cancer staging: A prospective study from a tertiary hospital cancer centre in the Western Cape. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2020. [DOI: 10.4102/sajo.v4i0.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Ai X, Liao X, Li J, Tang P, Jiang J. Clinical Outcomes of N3 Breast Cancer: A Real-World Study of a Single Institution and the US Surveillance, Epidemiology, and End Results (SEER) Database. Cancer Manag Res 2020; 12:5331-5343. [PMID: 32753951 PMCID: PMC7342555 DOI: 10.2147/cmar.s246162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/01/2020] [Indexed: 11/23/2022] Open
Abstract
Background Although stage IIIC (any TN3M0) breast cancer is known to have a dismal prognosis, the clinical outcome of current standard management and the prognostic differences between N3a, N3b and N3c remain to be further investigated. Material and Methods Data from our center on pathologic N3 (pN3) (n=284) breast cancer and the US Surveillance, Epidemiology, and End Results (SEER) database on clinical N3 (cN3) (n=15,291) and M1 (n=23,623) breast cancer between January 2004 and December 2015 were systematically analyzed for clinicopathological characteristics and survival outcomes. Results In our institution, patients with pN3c had the worst survival, with 5-year OS and DFS rates of 52.4% and 41.5%, respectively. Patients with pN3b had a relatively good prognosis, with a 5-year OS rate of 75.3% vs 63.9% for the pN3a group (p=0.045). For DFS, the 5-year survival rate was 63.1% in the pN3b group compared with 40.3% in the pN3a group (p=0.030). In the US SEER database, patients with cN3c had the worst survival in the cN3 group, but the prognosis of cN3c was much better than that of M1. Similarly, patients with cN3b had a better prognosis compared with patients in other groups, with a 5-year OS rate of 68.9% vs 61.9% for the cN3a group (p<0.001) and a 5-year BCSS rate of 73.4% vs 67.1% for the cN3a group (p<0.001). Conclusion Breast cancer patients with N3c had the worst clinical outcomes, while the prognosis of N3b patients was better than that of N3a patients.
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Affiliation(s)
- Xiang Ai
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, People's Republic of China
| | - Xin Liao
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, People's Republic of China
| | - Junyan Li
- Department of Breast Surgery, People's Hospital of DeYang City, Deyang 618000, People's Republic of China
| | - Peng Tang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, People's Republic of China
| | - Jun Jiang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, People's Republic of China
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Neck Dissection for Cervical Lymph Node Metastases from Remote Primary Malignancies. ACTA ACUST UNITED AC 2020; 56:medicina56070343. [PMID: 32664344 PMCID: PMC7404558 DOI: 10.3390/medicina56070343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/03/2020] [Accepted: 07/07/2020] [Indexed: 12/25/2022]
Abstract
Background and Objectives: Patients with cervical lymph node metastases from remote primary tumours have poor prognoses because of the advanced stage of their cancer. Owing to recent progress in the nonsurgical management of various cancer types, options for surgical treatment to reduce tumour volume are increasing, and may help improve survival rates. For example, neck dissection may be a good option as a definitive therapy for some patients with resectable cervical metastases. We assessed patients who underwent neck dissection with curative intent and discuss the effectiveness of this approach for cervical metastases from remote malignancies. Material and Methods: We retrospectively reviewed the data of 18 patients (10 males and 8 females in an age range of 30–79 years) who underwent neck dissections for neck lymph node metastases from a remote primary tumour between 2010 and 2019. Patient clinical characteristics, preoperative accuracy of positive node localisation using fluorodeoxyglucose positron emission tomography–computed tomography (FDG/PET-CT), and patient survival rates were estimated. Results: Primary sites included ten lungs, two mammary glands, one thymus, one thoracic oesophagus, one stomach, one uterine cervix, one ovary, and one testis per patient. There were 19 levels with FDG/PET-CT positive nodes in 17 out of 18 patients. Conversely, there were 28 pathological positive levels out of 50 dissected levels. The sensitivity, specificity, positive and negative predictive values, and accuracy of FDG-PET/CT in predicting positive nodes were 69%, 88%, 95%, 47%, and 74%, respectively. The three-year overall survival (OS) rate for all patients was 70%. The three-year OS rate of the group with zero or one pathological positive nodes was 81%, which was significantly higher than that of the group with more than two positive nodes (51%) (p = 0.03). Conclusions: Neck dissection for cervical lymph node metastases from remote primary malignancies may improve prognoses, especially considering anticancer agents and radiotherapy advancements.
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Rebol J, Balon P, Kokol P, Švagan M. Distribution of Neck Metastases and Survival in Patients with Breast Carcinoma. Oncol Res Treat 2020; 43:380-387. [PMID: 32564015 DOI: 10.1159/000508138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 04/22/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Neck metastases in breast carcinoma are relatively rare and patients show poor survival rates. A controversy exists over whether neck metastases can be treated as distant or loco-regional metastases. The literature concerning the distribution of metastases in the neck is lacking, as well as data about whether metastases in the higher neck regions cause poorer survival than those in the supraclavicular fossa. METHODS Ultrasound investigation with fine-needle biopsy was performed on 41 breast cancer and confirmed neck metastases patients in a 6-year period. We analysed the distribution of neck metastases and patient survival rates using Kaplan-Meier survival curves and Cox regression. RESULTS The median survival time from the diagnosis of primary disease to that of neck metastases was 21 months. The presence of metastases in sites other than the neck significantly worsened survival, but multiple metastatic sites did not make it significantly worse. The number of nodes and presence of conglomerates did not considerably affect survival. CONCLUSION Neck metastases in breast carcinoma can be found not only in the supraclavicular fossa, but elsewhere in the neck as well. Survival of patients with metastases in higher neck regions was shorter, but not very much so. Survival of patients with metastases limited just to the neck was substantially better, therefore early detection and aggressive treatment that could include neck dissection should be considered.
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Affiliation(s)
- Janez Rebol
- Department of Otorhinolaryngology and Maxillofacial Surgery, Maribor University Clinical Center, Maribor, Slovenia, .,Medical Faculty, University of Maribor, Maribor, Slovenia,
| | - Peter Balon
- Medical Faculty, University of Maribor, Maribor, Slovenia
| | - Peter Kokol
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
| | - Matija Švagan
- Department of Otorhinolaryngology and Maxillofacial Surgery, Maribor University Clinical Center, Maribor, Slovenia
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Buchholz TA, Ali S, Hunt KK. Multidisciplinary Management of Locoregional Recurrent Breast Cancer. J Clin Oncol 2020; 38:2321-2328. [PMID: 32442059 DOI: 10.1200/jco.19.02806] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Thomas A Buchholz
- Division of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, CA
| | - Sonia Ali
- Division of Medical Oncology, Scripps MD Anderson Cancer Center, San Diego, CA
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Magnoni F, Colleoni M, Mattar D, Corso G, Bagnardi V, Frassoni S, Santomauro G, Jereczek-Fossa BA, Veronesi P, Galimberti V, Sacchini V, Intra M. Contralateral Axillary Lymph Node Metastases from Breast Carcinoma: Is it Time to Review TNM Cancer Staging? Ann Surg Oncol 2020; 27:4488-4499. [PMID: 32436193 DOI: 10.1245/s10434-020-08605-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contralateral axillary lymph node metastasis (CAM) is an infrequent clinical condition currently considered an M1, stage IV, disease. Due to the absence of shared data on CAM significance and on its therapeutic approach, be it curative or simply palliative, its management is still uncertain and undoubtedly represents a clinical challenge. PATIENTS AND METHODS Patients with pathologically confirmed metachronous CAM were retrospectively evaluated. All patients had been managed at the European Institute of Oncology, Milan, Italy, from 1997. Patients with distant metastases at the time of CAM were excluded. Possible treatments included surgery, systemic therapy and RT (radiotherapy). Outcomes were evaluated as rates of disease-free survival (DFS) and of overall survival (OS). RESULTS Forty-seven patients with CAM were included in the study. Metachronous CAM occurred 73 months (range 5-500 months) after diagnosis of the primary tumor. The median follow-up time was 5.4 years (interquartile range 2.9-7.0 years). The estimated OS was 72% at 5 years (95% CI 54-83), and 61% at 8 years (95% CI 43-75). The estimated DFS was 61% at 5 years (95% CI 44-74), and 42% at 8 years (95% CI 25-59). CONCLUSION These findings, together with those from previous studies, show that CAM outcome, particularly if measured as OS, appear better than at other sites of distant dissemination, when CAM is subjected to surgical and systemic treatments with a curative intent. Therefore, a new clinical scenario is suggested where, in the TNM system, CAM is no longer classified as a stage IV, but as an N3 disease.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy.
| | - M Colleoni
- Division of Breast Cancer Medical Treatments, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - D Mattar
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - G Corso
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy.,Faculty of Medicine, University of Milan, Milan, Italy
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - S Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - G Santomauro
- Service of Data Management, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - B A Jereczek-Fossa
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Radiotherapy, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - P Veronesi
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy.,Faculty of Medicine, University of Milan, Milan, Italy
| | - V Galimberti
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - V Sacchini
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy.,Faculty of Medicine, University of Milan, Milan, Italy
| | - M Intra
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy
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38
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Magnoni F, Intra M. ASO Author Reflections: Future View: A Recent Scientific Contribution Towards a Staging Revision of Contralateral Axillary Lymph Node Metastases from Breast Cancer. Ann Surg Oncol 2020; 27:4500-4501. [PMID: 32430751 DOI: 10.1245/s10434-020-08612-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Francesca Magnoni
- Division of Breast Cancer Surgery, European Institute of Oncology, IRCCS, Milan, Italy.
| | - Mattia Intra
- Department of Surgery, European Institute of Oncology, IRCCS, Milan, Italy
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Impact of 18F-FDG PET/MR on therapeutic management in high risk primary breast cancer patients - A prospective evaluation of staging algorithms. Eur J Radiol 2020; 128:108975. [PMID: 32371185 DOI: 10.1016/j.ejrad.2020.108975] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/27/2020] [Accepted: 03/23/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE To investigate whether potential differences in staging between a traditional staging imaging algorithm and 18F-FDG PET/MR lead to a change in patient management in breast carcinoma and to compare the diagnostic accuracy between the traditional staging algorithm and 18F-FDG PET/MR for the TNM classification. METHOD In this prospective cohort study from two university hospitals 56 women with newly diagnosed, therapy-naive breast cancer and increased pre-test probability for distant metastases were included. All patients were examined by a traditional staging imaging algorithm (X-ray mammography, breast ultrasonography, chest plain radiography, bone scintigraphy, and ultrasonography of the liver and axillary fossa) and whole-body 18F-FDG PET/MR including dedicated 18F-FDG PET/MR breast examinations. Each patient was discussed two times in a separate tumor board session to determine a total of three therapy recommendations based on histopathological data of the primary tumor and (1) traditional algorithm only, (2) traditional algorithm and 18F-FDG PET/MR, and (3) 18F-FDG PET/MR only. Major changes in therapy recommendations and differences between the traditional staging algorithm and 18F-FDG PET/MR for the TNM classification were evaluated. RESULTS Staging by 18F-FDG PET/MR led to a difference in treatment compared the traditional staging algorithm in 8/56 cases (14%). Therapy changes included therapy of the breast, locoregional nodes and systemic therapy. A trend to staging superiority was found for 18F-FDG PET/MRI without statistical significance (p = 0.3827). CONCLUSION In conclusion, for breast cancer patients with elevated pre-test probability for distant metastases a change of the therapy regiment occurs in 14 % of patients when staged by 18F-FDG PET/MR and confirmed by histopathology compared to a traditional staging algorithm. In particular with regard to the amendment of the guideline further assessment of 18F-FDG-PET/MR in this setting is necessary to assess the true value of this modality.
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Ai X, Wang M, Li J, Hu Y, Hou L, Zheng X, Yan Y, Pan Q, Jin Y, Liu W, Tan X, Tian Y, Zhang Y, Tang P, Jiang J. Supraclavicular lymph node dissection with radiotherapy versus radiotherapy alone for operable breast cancer with synchronous ipsilateral supraclavicular lymph node metastases: a real-world cohort study. Gland Surg 2020; 9:329-341. [PMID: 32420257 DOI: 10.21037/gs.2020.03.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The role of supraclavicular lymph node dissection (SCLD) in the treatment of breast cancer with ipsilateral supraclavicular lymph node metastasis (ISLM) remains controversial. We evaluated the role of SCLD in the treatment of breast cancer with ISLM and identified patients who may benefit from SCLD. Methods Data on patients presenting with breast cancer to the Breast Disease Center, Southwest Hospital, The Army Medical University from January 2004 and December 2017 were retrospectively screened. The median duration of follow-up was 36 months (2-175 months). 305 patients who were recently diagnosed with ISLM were eligible for the analysis. Results Overall, 9,236 women presented with breast cancer during the study period. Among the patients included, 146 and 159 received SCLD with radiotherapy (RT) and RT alone, respectively. Synchronous ISLM without distant metastases were present in 3.6% cases. The 3- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 79.5% and 73.9%, respectively, and 67.5% and 54.8%, respectively. However, SCLD with RT was not associated with superior survival on both univariate and multivariate analyses. On stratified analyses, patients with non-luminal A tumors with 4-9 positive axillary lymph nodes who underwent SCLD with RT had both superior OS (HR =5.296; 95% CI: 1.857-15.107; P=0.001) and DFS (HR =5.331; 95% CI: 2.348-12.108; P<0.001) compared with those who received RT alone. Conclusions SCLD may not beneficial in improving survival for unselected breast cancer patients with ISLNM. There is less of a tendency to perform SCLD in the luminal A group.
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Affiliation(s)
- Xiang Ai
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Minghao Wang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Junyan Li
- Department of Breast Surgery, People's Hospital of DeYang City, Deyang 618000, China
| | - Ying Hu
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Lingmi Hou
- Department of Thyroid Breast Surgery, First Affiliated Hospital, North Sichuan Medical College, Nanchong 637000, China
| | - Xiaodong Zheng
- Department of Breast Surgery, Chongqing University Cancer Hospital, Chongqing 40044, China
| | - Yuzhao Yan
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Qinwen Pan
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Yuting Jin
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Wei Liu
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Xuanni Tan
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Yuan Tian
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Yi Zhang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Peng Tang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
| | - Jun Jiang
- Breast Disease Center, Southwest Hospital, The Army Military Medical University, Chongqing 400038, China
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Kim JS, Kim K, Shin KH, Kim JH, Ahn SD, Kim SS, Kim YB, Chang JS, Choi DH, Park W, Kim TH, Chun M, Cha J, Kim JH, Lee DS, Lee SY, Park HJ. Cervical Lymph Node Involvement above the Supraclavicular Fossa in Breast Cancer: Comparison with Stage IIIC (KROG 18-02). J Breast Cancer 2020; 23:194-204. [PMID: 32395378 PMCID: PMC7192748 DOI: 10.4048/jbc.2020.23.e14] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 02/04/2020] [Indexed: 01/03/2023] Open
Abstract
Purpose We aimed to analyze the treatment outcomes of ipsilateral cervical lymph node (CLN)-positive breast cancer without other distant metastasis and compare the outcomes with those of supraclavicular lymph node (SCL)-positive breast cancer. Methods Seventy-eight patients with breast cancer and ipsilateral CLN metastasis above the supraclavicular fossa (CLN[+] group) were treated at 7 institutions (2000–2014). Seventy-four patients received systemic chemotherapy and breast surgery followed by locoregional radiotherapy. Outcomes of the CLN(+) group were compared with those of the SCL(+) group, which included 183 patients with SCL involvement. Results The median follow-up duration was 55.9 months. Twenty-two regional failures were found in 15 patients—axillary lymph node (LN) in 8, SCL in 6, internal mammary LN in 3, previously involved CLN in 4, and previously uninvolved ipsilateral CLN in one patient. The 5-year overall survival (OS), disease-free survival (DFS), locoregional relapse-free survival (LRRFS), and distant metastasis-free survival (DMFS) rates were 68.6%, 46.7%, 68.4%, and 57.0%, respectively. Neck dissection did not improve LRRFS and DFS (p = 0.86 and p = 0.26, respectively). Multivariate analysis showed that hormone receptor negativity and the presence of extracapsular extension were prognostic factors for poor DFS. On comparison with stage IIIC using propensity score matching, survival outcomes of the CLN(+) and SCL(+) groups were not different (5-year OS, p = 0.75; DFS, p = 0.88; LRRFS, p = 0.86; and DMFS, p = 0.45). Conclusion The comparable clinical outcomes indicate that patients with breast cancer who have ipsilateral CLN metastasis without other distant metastasis may benefit from locoregional treatment of the ipsilateral breast and systemic therapies, as do those with N3c disease.
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Affiliation(s)
- Jae Sik Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyun Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Mison Chun
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Korea
| | - Jihye Cha
- Department of Radiation Oncology, Wonju Severance Christian Hospital, Wonju, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Soo Lee
- Department of Radiation Oncology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Sun Young Lee
- Department of Radiation Oncology, Jeonbuk National University Hospital, Jeonju, Korea
| | - Hae Jin Park
- Department of Radiation Oncology, Hanyang University College of Medicine, Seoul, Korea
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Wong RX, Kusumawidjaja G, Tan V. Solitary contralateral axillary metastasis in breast cancer: Is it a true distant spread? Breast J 2019; 26:1493-1494. [DOI: 10.1111/tbj.13733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/01/2019] [Accepted: 12/05/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Ru Xin Wong
- Division of Radiation Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Grace Kusumawidjaja
- Division of Radiation Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Veronique Tan
- Division of Breast Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
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Surgery of the Primary Tumor Offers Survival Benefits of Breast Cancer with Synchronous Ipsilateral Supraclavicular Lymph Node Metastasis. World J Surg 2019; 44:1163-1172. [PMID: 31773219 DOI: 10.1007/s00268-019-05293-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Controversy exists around the locoregional management of the primary tumor for breast cancer associated with synchronous ipsilateral supraclavicular lymph node metastasis (sISLM) due to the rarity of the disease and limited available data. This study aimed to compare outcomes of patients in the Surveillance, Epidemiology, and End Results (SEER) database with sISLM who underwent surgical resection and radiation of the primary tumor with those who did not. METHODS This population-based retrospective study included breast cancer patients with sISLM without distant metastases from 2004 to 2016 in the SEER database. In this study, patients had been stratified by operative management, and propensity score matching (PSM) had been successfully applied. RESULTS A total of 1172 breast cancer patients with sISLM were included in the study: 863 (73.6%) of patients underwent the primary tumor resection, and 309 (26.4%) patients did not undergo surgery. The median survival time in the surgery group was longer compared to the nonsurgery group in the overall cohort and the PSM cohort. We concluded that the primary tumor resection was associated with improved survival. Subgroup analysis further demonstrated that local surgery was not inferior to radical surgery. CONCLUSION For selected breast cancer patients with sISLM, surgery is a promising local intervention which may improve the survival.
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Zhu J, Jiao D, Guo X, Qiao J, Ma Y, Zhang J, Chen H, Xiao H, Yang Y, Lu Z, Liu Z. Predictive factors and prognostic value of pathologic complete response of ipsilateral supraclavicular lymph nodes in breast cancer after neoadjuvant chemotherapy. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:666. [PMID: 31930067 DOI: 10.21037/atm.2019.10.22] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Breast cancer with ipsilateral supraclavicular lymph node metastasis is one of the indicators of poor prognosis. Patients who attain pathologic complete response in breast and axillary sites have improved survival and are highest in aggressive HR-HER2- and HER2-positive tumor subtypes. However, there is no study on the related factors and prognostic value of supraclavicular pathologic complete response in breast cancer after neoadjuvant chemotherapy. The aim of our work was to investigate the factors and prognostic significance of pathologic complete response of ipsilateral supraclavicular lymph node metastasis in breast cancer after neoadjuvant chemotherapy. Methods A total of 214 patients with breast cancer who had primary ISLN metastasis, receiving NAC and subsequent ISLN dissection, were retrospectively and consecutively reviewed. Univariate and multivariate analyses were performed using χ2 test and the logistic regression model, and the prognosis was analyzed by Kaplan-Meier curve. Results All patients included were women who were 26-74 years old. The rate of supraclavicular pathologic complete response (pCR) was 53.7%. Multivariate analysis showed that the expression of Ki67, breast pCR, and axillary pCR were independent predictors of supraclavicular pCR (P<0.05). After a median follow-up of 16.2 months, the risk of recurrence and metastasis in patients with supraclavicular pCR was half reduced compared to that of the non-pCR group (HR 0.51, 95% CI, 0.32-0.80, P<0.01), mainly manifested in HR-HER2- and HER2-positive disease. Conclusions The expression level of Ki67, breast pCR, and axillary pCR were independent predictors of supraclavicular pCR. Supraclavicular pCR was an independent predictor of disease-free survival (DFS). Surgical removal of supraclavicular lymph nodes can accurately evaluate the rate of supraclavicular pCR, which is of great significance for patient prognosis.
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Affiliation(s)
- Jiujun Zhu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Dechuang Jiao
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Xuhui Guo
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Jianghua Qiao
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Youzhao Ma
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Jingyang Zhang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Hui Chen
- People's Hospital of Zhengzhou, Zhengzhou 450008, China
| | - Hui Xiao
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Yue Yang
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Zhenduo Lu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
| | - Zhenzhen Liu
- Department of Breast Surgery, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou 450008, China
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de Haan R, van Werkhoven E, van den Heuvel M, Peulen HMU, Sonke GS, Elkhuizen P, van den Brekel MWM, Tesselaar MET, Vens C, Schellens JHM, van Triest B, Verheij M. Study protocols of three parallel phase 1 trials combining radical radiotherapy with the PARP inhibitor olaparib. BMC Cancer 2019; 19:901. [PMID: 31500595 PMCID: PMC6734274 DOI: 10.1186/s12885-019-6121-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 09/02/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Poly (ADP-ribose) Polymerase (PARP) inhibitors are promising novel radiosensitisers. Pre-clinical models have demonstrated potent and tumour-specific radiosensitisation by PARP inhibitors. Olaparib is a PARP inhibitor with a favourable safety profile in comparison to clinically used radiosensitisers including cisplatin when used as single agent. However, data on safety, tolerability and efficacy of olaparib in combination with radiotherapy are limited. METHODS Olaparib is dose escalated in combination with radical (chemo-)radiotherapy regimens for non-small cell lung cancer (NSCLC), breast cancer and head and neck squamous cell carcinoma (HNSCC) in three parallel single institution phase 1 trials. All trials investigate a combination treatment of olaparib and radiotherapy, the NSCLC trial also investigates a triple combination of olaparib, radiotherapy and concurrent low dose cisplatin. The primary objective is to identify the maximum tolerated dose of olaparib in these combination treatments, defined as the dose closest to but not exceeding a 15% probability of dose limiting toxicity. Each trial has a separate dose limiting toxicity definition, taking into account incidence, duration and severity of expected toxicities without olaparib. Dose escalation is performed using a time-to-event continual reassessment method (TITE-CRM). TITE-CRM enables the incorporation of late onset toxicity until one year after treatment in the dose limiting toxicity definition while maintaining an acceptable trial duration. Olaparib treatment starts two days before radiotherapy and continues during weekends until two days after radiotherapy. Olaparib will also be given two weeks and one week before radiotherapy in the breast cancer trial and HNSCC trial respectively to allow for translational research. Toxicity is scored using common terminology criteria for adverse events (CTCAE) version 4.03. Blood samples, and tumour biopsies in the breast cancer trial, are collected for pharmacokinetic and pharmacodynamic analyses. DISCUSSION We designed three parallel phase 1 trials to assess the safety and tolerability of the PARP inhibitor olaparib in combination with radical (chemo-)radiotherapy treatment regimens. PARP inhibitors have the potential to improve outcomes in patients treated with radical (chemo-)radiotherapy, by achieving higher locoregional control rates and/or less treatment associated toxicity. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT01562210 (registered March 23, 2012), NCT02227082 (retrospectively registered August 27, 2014), NCT02229656 (registered September 1, 2014).
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Affiliation(s)
- R. de Haan
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - E. van Werkhoven
- Department of Biometrics, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - M.M. van den Heuvel
- Department of Thoracic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX The Netherlands
| | - H. M. U. Peulen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - G. S. Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - P. Elkhuizen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - M. W. M. van den Brekel
- Department of Head and Neck Surgery and Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - M. E. T. Tesselaar
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - C. Vens
- Division of Cell Biology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - J. H. M. Schellens
- Division of Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - B. van Triest
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - M. Verheij
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Division of Cell Biology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Solej M, Ferronato M, Nano M. Locally Advanced Breast Cancer in the Elderly: Curettage Mastectomy. TUMORI JOURNAL 2019; 91:321-4. [PMID: 16277097 DOI: 10.1177/030089160509100407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Locally advanced breast tumor represents 5–20% of new cases diagnosed every year. The purpose of this study was to report our experience and to compare it with the literature. Methods From 1998 to 2003 at the Molinette Hospital in the Turin University Third Division of General Surgery, there were 34 cases of breast cancer in older women (between 70 and 94 years of age), 14 of which (41.18%) were locally advanced breast tumor. We evaluated the type of surgical intervention and anesthesia used, muscular invasion, the presence of receptors positive to estrogens and progesterone, the operative mortality, the percentage of local-regional recurrence, and relapses after a period of time. Results Among the patients with locally advanced breast tumor, 21.43% (3/14) were at stage MIA and 78.57% (11/14) at stage IIIB. In 14.29% (2/14) of the cases, Patey's radical mastectomy was performed, in 57.14% (8/14) Halsted's radical mastectomy, and in 28.57% (4/14) a simple mastectomy with the removal of the fascia of the major pectoral muscle. Three (21.43%) patients underwent a second intervention for local-regional disease. None of the patients had distant metastasis in the first 2 years after the operation. Mortality after 2 years was 23.1% (3/13). None of the patients who underwent surgery had adjuvant therapy, usually because it was refused by the patients themselves or their families. All the negative and positive hormone receptor patients received tamoxifen. Conclusions Locally advanced breast tumors are frequent in elderly women. In the past, there has been a tendency to surgical under-treatment. As regards locally advanced breast tumor, curettage operations represent the only possibility to improve the quality of life of the elderly. These should be performed after carefully evaluating a series of variables in the general and local condition of the patient, the aggressiveness of the intervention and the life expectancy.
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Affiliation(s)
- Mario Solej
- Department of Clinical Pathophysiology, Third Division of General Surgery, San Giovanni Battista Hospital, University of Turin, Italy.
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Christopherson K, Lei X, Barcenas C, Buchholz TA, Garg N, Hoffman KE, Kuerer HM, Mittendorf E, Perkins G, Shaitelman SF, Smith GL, Stauder M, Strom EA, Tereffe W, Woodward WA, Smith BD. Outcomes of Curative-Intent Treatment for Patients With Breast Cancer Presenting With Sternal or Mediastinal Involvement. Int J Radiat Oncol Biol Phys 2019; 104:574-581. [PMID: 30851348 DOI: 10.1016/j.ijrobp.2019.02.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 01/16/2023]
Abstract
PURPOSE Optimal treatment of patients diagnosed with de novo metastatic breast cancer limited to the mediastinum or sternum has never been delineated. Herein, we sought to determine the efficacy of multimodality treatment, including metastasis-directed radiation therapy, in curing patients with this presentation. METHODS AND MATERIALS This is a single-institution retrospective cohort study of patients with de novo metastatic breast cancer treated from 2005 to 2014, with a 50-month median follow-up for the primary cohort. The primary patient cohort had metastasis limited to the mediastinum/sternum treated with curative intent (n = 35). We also included a cohort of patients with stage IIIC disease treated with curative intent (n = 244). Additional groups included a mediastinal/sternal palliative cohort (treatment did not include metastasis-directed radiation therapy; n = 14) and all other patients with de novo stage IV disease (palliative cohort; n = 1185). The primary study outcomes included locoregional recurrence-free survival (LRRFS), recurrence-free survival (RFS), and overall survival (OS), which were calculated using the Kaplan-Meier method. Cox multivariable models compared survival outcomes across treatment cohorts adjusted for molecular subtype, age, and race. RESULTS For the mediastinal/sternal curative-intent cohort, 5-year LRRFS was 85%, RFS was 52%, and OS was 63%. After adjustment, there was no statistically significant difference in LRRFS (hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.13-1.13; P = .08), RFS (HR, 0.87; 95% CI 0.50-1.49; P = .61), or OS (HR, 0.79; 95% CI 0.44-1.43; P = .44) between the stage IIIC cohort and the mediastinal/sternal curative-intent cohort (referent). In contrast, RFS was worse for the mediastinal/sternal palliative cohort (HR, 2.29; 95% CI 1.05-5.00; P = .04). OS was worst for the de novo stage IV palliative cohort (HR, 2.61; 95% CI 1.50-4.53; P < .001). CONCLUSIONS For select patients presenting with breast cancer metastatic to the sternum and/or mediastinum, curative-intent treatment with chemotherapy, surgery, and radiation yields outcomes similar to those of stage IIIC disease and superior to de novo stage IV breast cancer treated with palliative intent.
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Affiliation(s)
- Kaitlin Christopherson
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiudong Lei
- Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos Barcenas
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Buchholz
- Department of Radiation Oncology, Scripps MD Anderson Cancer Center, San Diego, California
| | - Naveen Garg
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Henry Mark Kuerer
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth Mittendorf
- Department of Surgical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - George Perkins
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Stauder
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric A Strom
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Welela Tereffe
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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The Prognostic Value of 18F-FDG Uptake in the Supraclavicular Lymph Node (N3c) on PET/CT in Patients With Locally Advanced Breast Cancer With Clinical N3c. Clin Nucl Med 2018; 44:e6-e12. [PMID: 30540598 DOI: 10.1097/rlu.0000000000002365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE We investigated the prognostic value of F-FDG uptake in the supraclavicular lymph node (SCLN) on PET/CT in breast cancer patients with clinical ipsilateral SCLN metastasis (cN3c). METHODS Fifty-five female patients with initial F-FDG PET/CT were treated with curative intent. For semiquantitative analysis, the SUVmax of the primary tumor, axillary lymph node, and SCLN were normalized by the SUVmean of the liver (defined as SUVR-tumor, SUVR-axillary lymph node, and SUVR-SCLN, respectively). Cox proportional hazards models were used to predict disease-free survival (DFS) and overall survival (OS). Differences in DFS and OS were assessed by Kaplan-Meier analysis. RESULTS Twenty-three patients (41.8%) experienced recurrence, and 13 (23.6%) died during follow-up (median, 70.0 months; range, 6-128 months). In multivariate analysis, SUVR-tumor greater than 3.26 (hazards ratio, 7.26; 95% confidence interval, 1.58-33.31; P = 0.01) and SUVR-SCLN greater than 1.05 (hazards ratio, 8.47; 95% confidence interval, 1.09-65.87; P = 0.04) were prognostic for OS. No clinicopathologic or PET/CT parameters were prognostic for DFS. The patients were divided into 3 groups: group 1 (n = 11, SUVR-tumor ≤3.26 and SUVR-SCLN ≤1.05); group 2 (n = 27, SUVR-tumor >3.26 or SUVR-SCLN >1.05); and group 3 (n = 17, SUVR-tumor >3.26 and SUVR-SCLN >1.05). The 5-year OS rates were 100% in group 1, 85.2% in group 2, and 51.0% in group 3. Group 3 showed worse prognosis than group 1 (P < 0.01) and group 2 (P < 0.01). CONCLUSIONS In addition to SUVR-tumor, SUVR-SCLN seemed to play an important role in selecting patients with the worst prognosis.
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Khater A, El-Badrawy A, Ebrahem MA. Stridor as the First Presentation of Metastatic Breast Cancer that Was Managed with Chemotherapy: a Case Report. Indian J Surg Oncol 2018; 9:336-339. [DOI: 10.1007/s13193-018-0724-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 01/11/2018] [Indexed: 11/29/2022] Open
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Chkheidze R, Sanders MAG, Haley B, Leitch AM, Sahoo S. Isolated Contralateral Axillary Lymph Node Involvement in Breast Cancer Represents a Locally Advanced Disease Not Distant Metastases. Clin Breast Cancer 2018; 18:298-304. [DOI: 10.1016/j.clbc.2017.10.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 10/17/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022]
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